Is Sleep Apnea Boring?

A few weeks ago I sat down in a hospital cafeteria. At my table was a polite, bright pulmonologist. He expressed sympathy for my work: “I find sleep apnea so boring.”

For a doctor like him there’s isn’t much clinically to do. A patient walks in. They snore. They’re tired in the daytime. Their spouse complains. There’s too much noise to sleep.

You send the patient to the Sleep Lab. She is found to have many stopped breathing episodes. You bring her back another night. You wake her at 5:30 in the morning, tell her she “did great.” The CPAP machine successfully opened her airway. You write out a CPAP prescription to the medical device vendor.

Your job is over. Done. Here's clinical boredom personified.

Except that most everything about this model of treating sleep apnea is wrong.

Including the boring part.

The Standard Medical Model

American medicine is a business, right? And in any business the goal is to make money.

Procedures make money.

When academics recognized how common sleep apnea was in 1980s, few foresaw it would become a monumental gravy train. Those who did did very well.

A few sleep labs soon mushroomed into thousands. Big money flowed to people who made laboratory equipment. Flakes of gold fell on physicians who ordered and read the studies. Yet the real buck came with CPAP devices — and their follow-up parts.

Manufacturers made billions. Still do.

The model was simple. First test — as many people as possible. Then give the ones who need them CPAP devices — in as many variants as possible.

2. The majority of people with sleep apnea have insomnia — plus many other sleep and medical problems.

3. Sleep apnea is just part of a much wider public health problem — metabolic syndrome. With the increase in obesity around the world, metabolic syndrome is set up to help kill hundreds of millions.

For sleep apnea is a systemic disease.

System Failure

Snoring used to be funny. It’s not anymore. For snoring marks a physiologic problem — the desynchronization of breathing and circulation.

When you have sleep apnea, your heart and lungs don’t fully work together.

This produces more than loud noises and daytime sleepiness. For life you need energy. That comes from oxygen (the lungs) flawlessly moving into the blood (the heart and blood vessels.) Foul up that process and the problems are numerous:

You need to get folks to see why they should use CPAP, and how it can be used. Which often means major changes in behavior.

D. People with sleep apnea usually have all sorts of sleep difficulties. The majority of people with sleep apnea have insomnia — even after they get a CPAP machine. Insomnia can be solved by a host of other techniques including: cognitive-behavioral treatment; getting people to go to bed and rise up at the same times each day (circadian treatment); weight loss achieved by walking after meals; rest-relaxation techniques.

It’s not just about the machine.

Profits or Health?

American health care is very good at generating income for large groups of people. It’s much less effective at providing health — physical, mental, social, and spiritual well-being.

Sleep apnea is a systemic illness. It affects many millions of people, their families, and their jobs. It has system-wide effects.

It needs systemic treatment.

To fix it in the future, we might start with banning junk food advertisements aimed at children. Recent evidence shows that if kids are obese at age five they’ll probably stay that way. The early years may count most.

But for those of us in clinical practice, the real issue is to accept that sleep apnea must be fully treated. Much can be done with very basic stuff: fixing people’s basic sleep habits plus how they eat, move, and rest. So that people can really function and enjoy life.

That involves talking to people. Encouraging them. Engaging their families.

It’s a lot of work.

CBT is often very effective. But just as with any psychotherapy, it doesn’t get paid anything like ordering sleep studies or CPAP machines. Often it doesn’t get paid at all.

This article is misleading. It says that obesity is the cause of sleep apnea, and implies that sleep apnea will be cured by weight loss. It also implies that weight loss is as simple as changing "habits and lifestyle." All of these claims are false.

I have severe sleep apnea that is caused not by obesity but because of the shape of my palette and neck area. Weight loss has nothing to do with my sleep apnea.

Second, it is well known now that weight loss is not a matter of just changing habits and lifestyle.

Dear Dr. Arnold,
You are correct when you say weight gain is not the single "cause" of sleep apnea. But can we talk about populations for a moment, rather than just our individual selves?
Yes, there are very, very thin individuals who have sleep apnea. There are genetic bases for sleep apnea. There are very obese people without sleep apnea.
But populations with lower weights have less sleep apnea - by a wide, wide margin. Many people who have sleep apnea and lose weight lose their sleep apnea. People may not love gastric bypass as a treatment for many reasons. Yet its effect on lowering sleep apnea rates is highly dramatic.
If Americans were smaller, there would be a lot less sleep apnea.
But you are correct - health is a much bigger issue than weight.
And health is not merely an issue of individuals. It's about populations, communities. It's about physical, mental, social and spiritual well-being.
Healthier lifestyles do lead to healthier populations - and ones with a lot less heart attacks, strokes, cancer.
And less sleep apnea.
I am sorry if you took what I wrote personally. But it is time to talk about the public health, and to think collectively.

I am one of those skinny sleep apnea patients as well. It sucks but the author is right that we're a pretty small bunch. We're lucky that it can also be caused by weight since without all those overweight people we wouldn't get nearly the attention we do. We might not even know what to call sleep apnea or have CPAP options.

He's sort of right on the genetic cause. The most significant anatomic cause are breathing problems during childhood, specifically mouth breathing. The biggest risk factor there is tendencies to airborne allergies. Genetics plays a factor there but so does where you live, epigenetics, diet, and getting early treatment for it. Allergies have been increasing in prevalence for the last century so this class of problems is quickly becoming more prevalent.

These problems can be fixed by behavioral changes today but sadly, not people the people who are afflicted by the problems. Prevention can only come from your parents.

Yes, it is true that the more obese you are the more likely that you would have sleep apnea; though, sleep apnea is not only caused by being severely overweight. There are people who are skinny and still show all the signs of sleep apnea. Also, are they working on other treatments besides the CPAP options? I don't have to use one personally, but I know of others who do and they claim it to be very uncomfortable and a pain at night. There should be other options.

Many people, previously including myself, do not realize other problems that come along with sleep apnea. Getting into bad sleep habits from sleep apnea can cause irregular and unhealthy sleep patterns. Unhealthy sleep patterns can cause insomnia and other sleeping disorders.

I know I for one take sleep for granted and sometimes forget how detrimental sleep is to my health. You talked in this article about how lack of sleep can affect so many aspects in our lives. I know I am interested to learn more and apply to my life.

Sleep Apnea as well as many other sleep disorders are in fact not boring but come with many complex problems that are quite intriguing.